Fillable Printable 21 609
Fillable Printable 21 609
21 609
IMPORTANT: Read Instructions on reverse before completing form. Type or print all information.
OMB Approved No. 2900-0064
Respondent Burden: 30 Mins.
APPLICATION FOR AMOUNTS DUE ESTATES
OF PERSON ENTITLED TO BENEFITS
6. FIRST NAME - MIDDLE NAME - LAST NAME OF CLAIMANT
1B. SOCIAL SECURITY NUMBER 2. VA FILE NUMBER1A. FIRST NAME - MIDDLE NAME - LAST NAME OF DECEASED VETERAN
3. FIRST NAME - MIDDLE NAME - LAST NAME OF DECEDENT 4. DATE OF BIRTH 5. LEGAL RESIDENCE
8. RELATIONSHIP TO DECEDENT
9. RELATIVE SURVIVING DECEDENT AT TIME OF DEATH WHO MAY BE ENTITLED TO SHARE IN THE ESTATE
PART I - INFORMATION RELATING TO DECEDENT WHOSE ESTATE IS ENTITLED TO BENEFITS
9A. NAME OF RELATIVE 9C. AGE
9B. RELATIONSHIP
TO DECEDENT
10. EXPENSES INCURRED FOR LAST SICKNESS AND BURIAL OF DECEDENT (See paragraph 4 of Instructions)
10A. NAME OF CREDITOR 10C. AMOUNT10B. NATURE OF EXPENSE
10D.
PAID OR
UNPAID
10E. BY WHOM PAID (If paid)
11. DID DECEDENT LEAVE ANY OTHER DEBTS?
12. NATURE AND AMOUNTS OF OTHER DEBTS?
13. HAS DECEDENT'S ESTATE BEEN
ADMINISTERED?
14. WILL DECEDENT'S ESTATE BE
ADMINISTERED?
15. DID DECEDENT LEAVE ANY ASSETS OTHER
THAN AMOUNT DUE FROM THE UNITED STATES?
16. NATURE AND VALUE OF OTHER ASSETS
17. WHY WERE ASSETS NOT USED TO PAY ANY UNPAID BILLS LISTED IN
ITEM 10?
19. TELEPHONE NUMBER(S) (Include Area Code)
20. DATE SIGNED
B. EVENINGA. DAYTIME
18. SIGNATURE OF CLAIMANT
(If "Yes," complete Items 16 and 17)
CERTIFICATION AND SIGNATURE OF CLAIMANT
I CERTIFY THAT the above statements are true and correct to the best of my knowledge and belief.
(If "No," complete Item 14)
(If "Yes," complete Item 12)
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
VA FORM
OCT 2002
21-609
EXISTING STOCKS OF VA FORM 21-609, FEB 2002,
WILL BE USED.
YES NO
YES NO YES NO YES NO
7.MAILING ADDRESS OF CLAIMANT (Number and Street or Rural Route, City or P.O., State and Zip Code)
9D. ADDRESS
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.
24. UNPAID CREDITOR NO. 4
23. UNPAID CREDITOR NO. 3
22. UNPAID CREDITOR NO. 2
PART II - STATEMENTS OF UNPAID CREDITORS
PRIVACY ACT INFORMATION: No allowance of death benefits may be granted unless this form is completed fully as required by law (38 U.S.C. 5101). The
responses you submit are considered confidential (38 U.S.C. 5701). VA may disclose the information that you provide outside VA only if the disclosure is authorized
under the Privacy Act, including the routine uses identified in the VA system of records, 58VA21/22 Compensation, Pension, Education, and Rehabilitation Records -
VA. The requested information is considered relevant and necessary to determine maximum benefits under the law. Information submitted is subject to verification
through computer matching programs with other Federal or state agencies for the purpose of determining your eligibility to receive VA benefits, as well as to collect any
amount owed to the United States by virtue of your participation in any benefit program administered by VA.
21. UNPAID CREDITOR NO. 1
I CERTIFY THAT the expense listed in Part I, Item 10 on reverse, which was incurred by the undersigned in connection with the last sickness and burial of decedent, is
due and unpaid; and that this statement is true and correct to the best of my knowledge and belief.
PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false, or for the fraudulent acceptance of any payment to which you are not entitled.
INSTRUCTIONS
B. ADDRESS OF CREDITOR OR NAME OF FIRM D. TITLE OF PERSON SIGNING FOR FIRM
E. DATE
A. SIGNATURE OF CREDITOR OR NAME OF FIRM C. SIGNATURE OF PERSON SIGNING FOR FIRM
B. ADDRESS OF CREDITOR OR NAME OF FIRM
D. TITLE OF PERSON SIGNING FOR FIRM
E. DATE
A. SIGNATURE OF CREDITOR OR NAME OF FIRM
C. SIGNATURE OF PERSON SIGNING FOR FIRM
B. ADDRESS OF CREDITOR OR NAME OF FIRM D. TITLE OF PERSON SIGNING FOR FIRM
E. DATE
A. SIGNATURE OF CREDITOR OR NAME OF FIRM C. SIGNATURE OF PERSON SIGNING FOR FIRM
B. ADDRESS OF CREDITOR OR NAME OF FIRM D. TITLE OF PERSON SIGNING FOR FIRM
E. DATE
A. SIGNATURE OF CREDITOR OR NAME OF FIRM C. SIGNATURE OF PERSON SIGNING FOR FIRM
1. This form is not to be used if there has been or will be legal administration upon the decedent's estate.
3. Applicants for payment of the amount due from the United States will avoid delay in settlement by carefully filling out this application and by
furnishing the specific information and supporting evidence required.
4. Each bill covering expenses of last sickness and burial, shown in Part I, Item 10 on reverse, should be submitted on the regular billhead of the creditor
and if paid, must be receipted to show by whom payment was made. If unpaid, claim should be made by such creditor on Part II of this form.
2. This amount due from the United States to the deceased at time of death is an asset of estate and is payable to the person or persons entitled thereto
under the laws governing the distribution of personal property in the State Territory where the deceased was legally domiciled at the time of death, in
the absence of Federal statutes otherwise providing.
